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Susan J. Noonan, MD, MPH emphasizes how we must know and be on the lookout for risk factors and warning signs of suicide.

is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

mental health and wellness virtual coaching practice, opening in July 2021, known as Noonan Wellness Coaching, and can be confidentially reached through her website at 

How can we help others in September, National Suicide Prevention Month?

Suicide Prevention Month Tips and Insights

Tales From the Clinic: The Art of Psychiatry

, we visit the addiction clinic to discuss accidental overdose deaths. Although death by suicide is known to greatly impact psychiatrists, the impact of overdose deaths on physicians is not well studied. Despite the best efforts exerted in treatment, patients on medications for opioid use disorder may die of accidental overdoses on opioids, having misestimated their current opioid tolerance, or overdose on other substances such as sedatives/hypnotics and stimulants. This article is dedicated to 3 patients lost in this past year—AK, EG, and AW—with heartfelt wishes to their families.

“Ms Verona” was a 45-year-old female enrolled in an addictions treatment program and a mother of 7 children who struggled greatly with 

 and anxiety. She was motivated to stop her opioid use, as it was taking a toll on her health and her family. Ms Verona’s children would sense their mother’s lack of engagement with them, as she was constantly preoccupied with how to mitigate the inevitable opioid withdrawal symptoms. She was a good candidate for buprenorphine therapy, as she met criteria for severe opioid use disorder, and she preferred partial agonist therapy as opposed to naltrexone and methadone. Ms Verona was inducted onto buprenorphine, and her dose subsequently increased to 16 mg total daily in order to adequately address opioid cravings.

As treatment progressed, Ms Verona displayed a chronic tendency to arrive more than an hour late to appointments. Despite her tardiness, she would plead to still be seen, often citing traffic or lack of childcare arrangements. The psychiatrist, Dr Smith, would attempt to be flexible, given the understanding of treatment barriers stemming from social determinants of health, as well as recognizing the time-sensitive nature of 

 refills; however, these accommodations were placing Dr Smith and the treatment team under time constraints in a busy clinic. Such accommodation would either cause the psychiatrist to be late for other appointments, or it would lead to the appointment with Ms Verona feeling rushed. After the patient was accommodated for lateness over a few visits, Dr Smith became aware of his growing countertransference toward Ms Verona.

 (ADHD) may have been affecting her presentation. Ms Verona was noticeably circumstantial during sessions and required frequent redirection. She also described a childhood history with symptoms of difficulty concentrating. It was also explored whether her lateness was a manifestation of her inability to focus, organize, and prioritize. She often talked about having gotten Adderall “but not recently, doctor; I know you would not let me.” Dr Smith worked with Ms Verona in problem-solving therapy to help reduce treatment-interfering behaviors and promote punctuality. Ms Verona was also started on bupropion to target ongoing depressive symptoms and simultaneously provide a nonnarcotic option to treat attention-deficit symptoms. There was a concern for her using stimulants or other substances between appointments. Despite these treatment approaches, tardiness to her appointments continued and she appeared even sedated at times, despite negative urine drug screens.

One day, Ms Verona was more than an hour late. She was informed that she could not be seen and had to be rescheduled. She was visibly upset and opted, likely due to splitting defense mechanism, to reschedule to see a different provider in the clinic when this boundary was set. After this, Ms Verona ended up seeing a different psychiatrist for the next 6 months.

One day, Ms Verona’s former psychiatrist met with one of his active patients, Mr Kim, and the following dialog ensued:

Mr Kim: “One of my friends passed away, and I’m attending the funeral. I think you actually used to treat her before.”

Dr Smith: (Somewhat surprised) “I’m sorry to hear about the loss of your friend.”

Mr Kim: “Yea, it was sad… she (Ms Verona) said she used to see you. She was still on buprenorphine, but the suspicion was that she was taking alprazolam the whole time she was in treatment and did not tell anybody, and it is a suspected unintentional overdose. I used to see her all the time, and she would be nodding off. You didn’t hear about this?”

How Do Physicians Cope With Patient Suicide or Overdose?

Dealing with the loss of a patient due to suicide or 

 has a significant impact on the treating physician and is not often talked about. There are a variety of factors that determine how a psychiatrist will be impacted in such a situation. Younger clinicians and trainees are often affected more adversely, as they have not been exposed to the scenario and may feel more vulnerable in terms of their experience and knowledge base.

 According to literature, about 25% to 60% of psychiatrists will report having a patient who died by suicide during their career.

 The number of physicians who lose patients to overdose is not known. However, the rate of overdoses involving opioids jumped by 200% from 2000 to 2014, and between 2013 to 2019, the synthetic opioid-involved death rate increased 1040%.

 The sheer magnitude of these numbers suggest that most physicians dealing with addiction must have been exposed to patient death by overdose.

With these figures in mind, as well as the significant amount of perceived stigma and guilt surrounding disclosure of these outcomes, and with the fear of lawsuits that may occur in these situations, the overall emotional toll it can have on a clinician can be quite intense. The psychiatrist in this scenario was flooded with feelings of guilt related to potential responsibility for the outcome. In addition, there is a possibility of additional emotions of anger toward the patient who was already deceased. We hear team members often saying, “Oh, but they were doing so well,” or “So sad—they stayed off heroin but could not keep off meth.”

When one is processing the suicide of a patient, one should be mindful to not isolate oneself. Efforts should be conducted to reach out to colleagues, as it is likely they would have dealt with similar experiences in the past and can normalize and validate the experience. Discussion of experiences and coping mechanisms may have therapeutic effects for physicians going through such experiences. Clinicians, as part of an organization or group practice, can utilize case conferences—a pragmatic, systematic, and therapeutic approach to exploring the case outcome in more detail. Risk management reviews or meetings could help with apprehension about any impending or perceived lawsuits. This is especially important for clinicians in private practice, who may be more isolated given their work environment structure. The message we need to hear is that a patient loss does not undo or discard the multitude of meaningful life-changing and life-preserving work done with both living and deceased patients. Support and validation go a long way in reminding us why we do what we do.

How Can We Promote Honesty About Recurrence of Substance Use?

 (SUDs), it may be helpful to try to acknowledge and normalize the fear of disclosure of relapses, as well as to emphasize the importance of honesty in recovery from the very beginning of treatment. Although feelings of guilt and internal shame are common, they are not easy to talk about for patients. Whereas the patient may perceive recurrence of use as “starting from scratch,” the clinician can reframe a recurrence of use as a learning point and a way to troubleshoot the circumstances surrounding the use. Being too harsh or strict with the patient may backfire, lead to sustain-talk, erode the therapeutic alliance, and provoke even more feelings of guilt or shame. Relapses sometimes occur because being off substances uncovers a cooccurring mental illness, or because of stress in real life, to which patients with SUDs are more susceptible.

By definition, addiction is a relapsing and remitting illness. Similarly, depression is also a relapsing and remitting illness, but no one benefits from being kicked out of treatment for having a recurrent depressive episode. Thus, patients should not be terminated from treatment for recurrence of use as if often done—they should actually receive more intense care when in a greater time of need. Although recurrence of use might have clinical significance on modifying treatment plans, patients should be informed that using is only a setback if they do not seek further treatment to address it. Patients may be relieved if asked about any internalized and unfounded fear they may have about being terminated from treatment if they divulge recurrence of use.

If a patient states that they are feeling punished for having more frequent visits during recurrence of use, it may help to first empathize with concerns and then reframe the change in treatment plans as a goal toward well-being as opposed to punishment. Utilization of motivational interviewing may be helpful if the patient is still ambivalent about recovery. It is crucial for a provider to have a nonjudgmental approach toward relapses, both past and present. Subconscious criticism, even in the form of subtle body language, can promote denial or reliance on more primitive defense mechanisms in a patient and lead to poorer treatment outcomes, especially if the patient has a harsh superego or difficulty with trusting others.

Previous recurrence of use may lead some patients to think they are a lost cause and lack the willpower and discipline that might be needed for recovery. Internalizing this belief is characteristic of patients with complicated SUD histories. It is important to modify a patient's internal process and remind them that it is not solely willpower or motivation that determines the ability to improve, but also coping and relapse prevention skills, which can be taught through any type of therapy, but especially cognitive-behavioral therapy.

How Do You Find a Balance of Boundaries With the Patient?

Finding the right balance in setting boundaries can be a challenge in a busy schedule, and it requires being mindful of the patient’s perspective while simultaneously acknowledging a patient’s subconscious need for structure to meet treatment goals.

It was important in Ms Verona’s case to validate her struggle with circumstances in her life. After all, the social determinants of health (ie, social, behavioral, and environmental factors) are a predominant influence on treatment outcomes.

 In addition, it is important to acknowledge the role of untreated ADHD (like in Ms Verona’s case) in reducing recovery success.

 At the same time, the medical ethics concept of justice should also be considered. Although justice in this situation may apply to acknowledging Ms Verona’s barriers to care, it may also expose the caveats of this approach since other waiting patients were affected by the patient’s tardiness. A provider is tasked with collectively benefiting all of their patients, treating all with equity and making accommodations where necessary, and without putting 1 patient at risk at expense of another.

In this case, did the boundary-setting change the course of Ms Verona’s clinical treatment? Yes. Would it have been better without it? Not necessarily. Part of the treatment frame is for both physician and patient to be accessible, at a mutually convenient time. Reneging on appropriate boundaries may distort or enable certain expectations of the patient, which can undermine the patient’s perceived responsibility in treatment, reduce the patient’s ability to problem-solve, and lead to the approach that the physician drives the treatment, instead of the dyad making a shared and mutual responsibility. The physician can communicate these messages with empathy and genuine concern in the hopes that the patient will adopt that responsibility. In the case of mitigating overdoses—a poorly understood field—it is essential to know if the patient is using secondary substances outside the opioid being the target of treatment. Secondary substance use significantly increases risk of overdose.

From a larger perspective, a physician’s taking of the alternate approach can contribute to burnout and distress, and potentially adversely affecting outcomes for the other patients. Thus, boundaries can be a mechanism of protection for both the patient and the physician.

Triple Threat of Death: Suicide, Unintentional Overdoses, and COVID-19

Although there is growing literature about how patient 

 can impact physicians, there is a lack of data particularly on how substance overdose may impact a physician’s mental well-being. The lack of data on overdoses and how to cope with them is further compounded by the problem that busy schedules or shift work may inadvertently reduce the physician’s ability to access resources for support while the physician also thinks that “I must carry on.”

In addition, it would be important to differentiate how suicide and overdose are not necessarily the same. Overdoses are not always done with the intention of taking one’s life. In fact, most overdoses are accidental, but ultimately occur due to overestimated tolerance, unknown ingestion, or increasing amounts taken during stressful/inciting events. In 2014, only 12% of drug overdoses were intentional according to the Centers for Disease Control and Prevention (CDC).

 Although the percentage of intentional overdoses is the minority, another thing to consider is whether clinician perception of guilt is more intense if the overdose is intentional. A physician can be vulnerable to guilt for not effectively being able to treat a patient’s addiction or form a close enough relationship to know of their usage—even if the patient knowingly did not disclose use. Then there is the question of whether some severe addictive disorders could be considered like a “terminal illness,” where a clinician may feel that no matter how many treatment approaches have been tried, it is a matter of “not if, but when” in regards to either overdose or a chronic decompensation toward death.

Although we have seen that doctors who hear about their patients overdosing may actually reduce the amount of their opioid prescribing,

 mental health clinicians may be affected in a somewhat different capacity, as their role is also tied inevitably into also treating comorbid depression, anxiety, and suicidal ideation. The COVID-19 pandemic has further exacerbated this problem, as the estimated prevalence of suicidal ideation today is higher in comparison to the prevalence prepandemic.

If a clinician’s natural tendency to do more and become more hypervigilant following the loss of a patient, it is noteworthy to mention that most physicians suffer from burnout at one point in their life. A cross-sectional study was able to demonstrate that increases in suicidal ideation endorsement were significantly correlated with physician burnout rates.

 Considering that overdoses can be as lethal as suicides, it would be a fair but unproven assumption that it would also similarly contribute to physician burnout.

We believe further research is necessary to understand the many ways in which patient overdoses are affecting physicians, as well as developing more efficient strategies and support for dealing with the aftermath. 

is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He is Director of Harris Health Substance Addiction Treatment Program and Associate Program Director for Baylor College of Medicine Addiction Fellowship Program. 

is currently a resident in psychiatry at Baylor College of Medicine. 

 is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, as well as the Ben Taub Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the 

1. Ruskin R, Sakinofsky I, Bagby RM, et al. 

Impact of patient suicide on psychiatrists and psychiatric trainees.

2. Plakun EM, Tillman JG. The impact of patient suicide on clinicians. 

https://www.psychiatrictimes.com/view/impact-patient-suicide-clinicians

3. Rudd RA, Aleshire N, Zibbell JE, Gladden M. Increases in drug and opioid overdose deaths - United States, 2000–2014. Centers for Disease Control and Prevention. Accessed September 12, 2022. 

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm

Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths - United States, 2013-2019.

Relapse prevention and the five rules of recovery.

6. Williams N, Bossert N, Chen Y, et al. 

Influence of social determinants of health and substance use characteristics on persons who use drugs pursuit of care for hepatitis C virus infection.

Adult attention-deficit hyperactivity disorders and its correlates in patients with opioid dependence: an exploratory study.

8. Austin AE, Proescholdbell SK, Creppage KE, Asbun A. 

Characteristics of self-inflicted drug overdose deaths in North Carolina.

Opioid prescribing decreases after learning of a patient's fatal overdose.

Suicide, self-harm and suicidal ideation during COVID-19: a systematic review.

11. Menon NK, Shanafelt TD, Sinsky CA, et al. 

Association of physician burnout with suicidal ideation and medical errors.

My Patient Overdosed and Now I Feel Guilty… 

As September is National Suicide Prevention Awareness Month, this article focuses on the exposure and affect regarding those who have been charged with protecting the population’s health and preserving a community’s population—namely, first responders.

In 2022, the world has been challenged by several unprecedented large-scale crisis events such as increases in 

, increases in violence, and pernicious natural disasters. Although first responders have been trained to engage in extreme conditions amid rapid onset of change circumstances, such trainings do not comprehensively address or provide resources for the post-response mental health needs of these professionals. In fact, because of the pandemic, alongside a host of other various social ingressions like public insurrections and aggressive social discord over the past 2 years, the mental health needs of first responders have gained more attention. In this, a larger scope of questions predominates, such as: What happens to those same professionals who continuously endure the gross impact of such phenomena beyond their psychological and physical capabilities? Additionally, what is being done to assist first responders regarding assessment and remediation of mental health issues? Finally, how prevalent are things like posttraumatic stress disorder (PTSD) and other pathologies that may result from being a first responder?

Definitive trends also underscore these kinds of questions regarding first responders and the pathos-defined issues that have emerged from studies that depict PTSD, suicide, depression, alcoholism, and drug abuse as most predominant among this group of professionals.

 Although this observation was made nearly a decade ago, current research shows these same trends have negatively increased in 2022.

As well, more sobering statistics from the Centers for Disease Control and Prevention (CDC) have found that occupational stress in first responders can be associated with increased risk of serious mental health issues including hopelessness, anxiety, depression, posttraumatic stress, and 

 such as suicidal ideation and actualized attempts.

The following article presents a purview and inquiry into how society, policy makers, and government agencies can begin to synthesize the current trends regarding the mental health issues of first responders, as well as their compromised and vulnerable realities, and emotional valance

 Additionally, this article examines a few of the current promising psychological preventatives being tested with first-responder populations and the future prospects to be considered for building mental health resources for this group.

To more clearly define “first responders,” one must consider the cross-segment of industry categorized as helping professionals, where the primary role is first-line contact in any emergency situation. For the purposes of this article, the author will refer to such a role primarily as “first responder”; however, this reference can be somewhat arbitrary, and first responders may also be characterized as “emergency response providers” or “public health workers.” Either way, first responders are those who must meet the challenging demands of their front-line status within roles that represent a collection of various helping professions.

Under the umbrella of those considered first responders are police officers, firefighters, and emergency medical technicians (EMTs). Given their occupational demands, these helping professionals are the ones who are also the most chronically exposed to stress and traumatic scenes in the line of duty on a daily basis. To expand on this, according to 

, the term “emergency response providers” might also include federal, state, and local governmental and nongovernmental emergency public safety, fire, law enforcement, emergency response, emergency medical (including hospital emergency facilities), and related personnel, agencies, and authorities.

The next section provides a look at some of the emergent literature that has been documented concerning the mental health sequelae of first responders and the psychopathology that may perseverate. This may include the artifacts of depression, anxiety, suicidal ideation, and a host of other variants.

Some statistics provided on first responders and their mental health have been documented by the US Department of Healthin a supplement from the Substance Abuse and Mental Health Administration Help for Heroes Program.

 The statistics reveal the following associated with firefighters, police officers, and EMS professionals

“It is estimated that 30 percent of first responders develop behavioral health conditions including, but not limited to, depression and [PTSD], as compared with 20% in the general population. In a study about suicidality, firefighters were reported to have higher attempt and ideation rates than the general population. In law enforcement, the estimates suggest between 125 and 300 police officers commit suicide every year.”

These are staggering results compared to those in other professions. If one reflects on the nature of each of these roles and what they are called to do to preserve life and community, the possibility of such tremendous role strain will always have some psychological implications. In looking at the work of firefighters, for example, these professionals are often the first on the scene in an emergency response call. “The nature of their work, including repeated exposure to painful and provocative experiences, and erratic sleep schedules, can impose significant risks to their mental health.”

 Thus, repeated exposure to hard circumstances that arise from crises are, by nature, psychically scarring and elevate the risk for future traumatic sequelae. To this end, one may add yet another insidious element of risk to be considered: intrinsic barriers that bar them from seeking help because of stigma, diminished capacity on the job, informal codes of silence, and treatment costs.

As with most exposure to extreme stressors, the elevated risk of things like anxiety, suicidal ideation, 

, and other issues may become more acute. Using the following example, according to research by Stanley et al, “over 50% of firefighter deaths are due to stress and extreme exhaustion.”

 In addition, “the suicidality of firefighters in yet another study revealed markedly greater elevated levels of posttraumatic stress from the profession, while career firefighters reported higher levels of PTSD.”

In turn, according to Bentley et al, an estimated 69% of EMS providers report not having enough recovery time between traumatic incidents.

 As most EMS providers are expected to be on duty for strenuous amounts of time—up to and beyond 24 hours—the duration and intensity of being on-call, engaging in extremely stressful situations, and having little opportunity for rest in between incidents becomes an unbalanced centrifuge of extraordinary circumstances to contend with that can lead to negative outcomes for the individual. Also, EMS workers typically experience greater noted degrees of problematic alcohol and drug use—more so than the general population.

 Like firefighters and police officers, most EMS personnel are reluctant to seek care due to fears of 

, irrational codes of silence, and fear of possible disciplinary action such as being put on leave or desk duty indefinitely.

In a number of studies, first responders showed disturbingly clear outcomes in reference to suicidal ideation. According to the studies, there was a 28% lifetime prevalence rate of feeling as though life was not worth living, 10.4% had more extreme instances of suicidal ideation, and 3.1% revealed past suicide attempts. As well, 37% of the first responders surveyed for 2 primary studies had contemplated suicide nearly 10 times more than the typical American adult. The lifetime prevalence of suicidal ideation among police officers was revealed to be 25% in female officers and 23% for male officers. Suicide attempt rates among police officers ranged from 0.7% to 55% in studies based on extensive literature reviews.

 As well, international analysis concerning suicides among law enforcement and their proportionate mortality ratios (PMRs)—or more so, the ratio of death count for this occupation compared to the expected number of deaths in all occupations combined—appeared significantly higher for all races and sexes combined (all law enforcement PMR equals 169%).

In the wake of the pandemic, the volatility and precarious nature of widescale crises only added to the extreme pressures of first responders. As we begin to uncover more data and evidence from the impact of the pandemic, much more will be learned about just how devastating and long-lasting those impacts have become. In the following section we look at some of the current resources being developed and implemented to address the needs of these professionals.

Part of the issue concerns the gap in research concerning a more comprehensive understanding of first-responder suicides. However, there have been several initiatives underway to help close this gap so that more enhanced resourcing is prevalent. One of the first steps was the construction of an interagency team of researchers composed from the National Highway Traffic Safety Administration (NHTSA) and the CDC’s National Center for Injury Prevention and Control (NCIPC), alongside the National Institute for Occupational Safety and Health (NIOSH).

This aggregated team of researchers is now analyzing and gathering more data around suicides of first responders using data from the most recent 3 years abstracted from the National Violent Death Reporting System (NVDRS). It is the only state-based surveillance system that aggregates data on the various types of violent deaths that include suicides. But why would suicides among first responders be an important data point to explore? Such specific data will actually help provide clarity around the circumstances of suicides among first responders. Although it can only provide a basic understanding of first-responder suicides, the information will be a significant start in the right direction for helping understand how first responders are dealing with extreme stress issues.

However, there are still inherent missing data elements that will need to be addressed to fill the voids in information and data collected. As a result, in 2020 the United States House and Senate had approved funding for this very need known as the Helping Emergency Responders Overcome (HERO) Act.

 This has led to legislation that directly incorporates the CDC to initiate a “public safety officer suicide reporting system” that will help increase and gather important and sometimes nuanced details around such events.

 Such legislation actually opens the door to promote research that will be targeted and directed toward helping first responders understand and hopefully circumvent negative outcomes in the future. These are the first in a series of promising steps.

With the number of mass shootings that have taken place over the years and the experience of first responders arriving at such scenes of mass destruction (which often are compared to war zones), investigators are starting to explore those effects most recently in regard to police, EMTs, and firefighters who attempt to control and manage real-time atrocities. Some studies have revealed distinct derivative similarities regarding military soldiers engaged in war and those who are repeatedly exposed to “warlike” environments, such as those in which first responders must work.

. As part of progressive steps to help first responders navigate the negative effects of the role, more and more clinics are using intensive outpatient programs (IOPs) as an avenue of hope. IOPs provide a more aggressive intervention path for first responders to be treated, which is being proposed and implemented as a possible conduit to regulating trauma symptomology. IOPs are designed to deliver treatment in a more rapid fashion, establishing rigorous psychosocial supports for participants and addressing relapse anchors while enhancing an individual’s coping skills.

 The IOP outpatient setting also provides clinicians the opportunity to work intensively with patients daily for an extended amount of time.

Deborah Beidel, a professor of psychology and medical education at the University of Central Florida, and her colleague, Amie Newins, an assistant professor of psychology at the same institution, are using IOPs as a way to help first responders. Both have been studying the effects of an empirically tested PTSD treatment program utilizing the IOP protocols that were originally developed for treating 

 in trauma management therapy. They have begun modifying this particular treatment over time to adjust for first responders. This program relies on some aspects of exposure therapy that offer a homeopathic opportunity that does not abruptly attempt to challenge fears, but rather, allows the individual the opportunity to gradually explore and diminish feelings in tandem with measured exposure to simulations that might create anxious states.

 As a result, when those first responders treated begin to understand that their reactions and feelings are not applicable to all situations, their fears—for instance, of large-scale benign events like concerts or meetings that may feel similar to a former mass crisis they may have worked in—may begin to lessen. In the results of their intensive outpatient program, Beidel and Newins found that about 70% of first responders who participated and demonstrated signs of PTSD no longer met the criteria after completing the program.

 Such experimental therapies like this one are beginning to show great promise, but more resources like this are still needed.

 Utilizing peer-to-peer sessions as a way to become more dialogic in communicating and processing various traumata is also finding its way into resourcing for first responders. Jeffrey Brown, PsyD, a private practitioner and assistant clinical professor in the Department of Psychiatry at Harvard Medical School, and Beth Meister, EdD, a private practitioner and also a clinical instructor at Harvard Medical School, were at the forefront of the very traumatic Boston Marathon bombing. At the time, both were working on the ground in a makeshift tent to help victims. As first responders at such a crisis-level event, both professionals were asked in interviews following the incident about their own self-care. Here is what they said

Brown: “I’ve been practicing what I preach: focusing on healthy eating, regular exercise, and a routine that includes ample sleep. While I’ve processed the event many times with patients who've brought their own experiences into therapy, I’ve also participated in a team support session and other meetings focused on shared experiences and support for medical team members directly exposed.”

Meister: “I attended a support session for race volunteers 2 weeks after the event, which was helpful. Although I felt no prominent after-effects, I tried to talk to family and friends about the experience when they asked and when I felt it would be helpful for me to talk. My initial anger at the loss of life, injury, destruction, and disruption of a sense of security has been replaced by a feeling of sadness when my mind goes to that day. I have found cognitive strategies helpful in dealing with the memories, just as I teach them to my patients.”

Peer support programs are being implemented both in the United States, Canada, and other countries across the world. They are steadily becoming part of frontline responder programs, such as police officer peer-support programs. One of the main goals of such programs is to help, for instance, police officers handle the exposure of daily stressors and traumatic material by being able to process it with a peer. The emergence of such programs evidenced greater proliferation during the 9/11 terrorist attacks in New York, where “a peer-based assistant program was found to be extremely beneficial in screening for stress-related symptoms amongst police officers, as well as helping them to process the aftermath of exposure to the 9/11 terrorist attacks in New York.”

. The rise of more “state-based programs similar to the program sponsored by the University of Texas Health Science Center at Houston have worked toward designing and implementing short continuing education (CE) virtual training programs specifically for first responders, describing how to recognize mental health and substance use issues in oneself or one’s peers. They have also established a statewide, completely confidential toll-free helpline (1-833-EMS-IN-TX) to provide screening, brief interventions, motivational interviewing, and other resources for first responders. Other states have formed similar programs.

 The hope is that more state agencies begin addressing the mental health needs of first responders as programs like this begin seeing results.

. Finally, another idea comes from the prospect of how such resources are marketed to both first responders and their agencies. Those working as mental health professionals need to find more creative ways to market the potential of counseling and therapy to first responders who might be hesitant to engage otherwise. Therapists can conduct agency trainings for first responders, volunteer for ride-alongs, or participate in community events with police officers, firefighters, and EMTs as first steps to initiating a mental health dialogue. A psychotherapeutic approach where first responders engage in counseling shows promise, with group therapy leading the way forward from the work of researcher Vallejo.17 In this particular study, first responders participated in psychoanalytically oriented group psychotherapy practice twice per week over a 3-month period. Utilizing a group of police officers (

 = 8) from Colombia who had been previously diagnosed with PTSD symptomology, the results of the study showed that posttraumatic stress symptomatology had improved in the trial sample after group psychotherapy was completed.

In a similar study, a randomized clinical trial (

 = 42) of Dutch police officers were sampled and divided into 2 distinct groups: an experimental group and a control group.

 In this study, the experimental group was given a combination of cognitive-behavioral and psychodynamic treatments for 16 weekly sessions. The findings of this study indicate that officers who attended psychotherapy for PTSD produced more significant improvements in altering their PTSD symptomatology compared with officers in the control group.

 Such results are again promising for the future of treatment possibilities for first responders.

The potential challenges faced by first responders have grown exponentially. As the nation counts on the heroic efforts displayed by these individuals daily in their line of work, policies and supplemental resourcing need to be modified to address the ever-burgeoning needs of this group. Some strategies, however, are beginning to take shape and show efficacious promise in fighting the deleterious effects that first responders might internally battle. More data is needed, though, to help understand the areas of opportunity available for continued research. As natural environmental impacts and socioeconomic issues continue to grow, so too must the efforts of research and policy to help sustain and treat the mental health needs of those we count on daily to arrive at and treat the victims of torrential situations. It is no longer a hope but an imperative that we address and help fortify one of the most valued and critical areas of professional avocation—namely, first responders.

is senior director of research strategy, innovation, and development in the College of Doctoral Studies at the 

, in addition to running his own private practice called Inspirethought Counseling.

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https://onlinedegrees.bradley.edu/blog/counseling-for-first-responders/

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https://blogs.cdc.gov/niosh-science-blog/2021/04/06/suicides-first-responders/

3. Domestic Security, 6 U.S.C. § 101 (2010). 

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https://helpforourheroes.com/first-responders-and-mental-health-issues

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http://www.revivingresponders.com/originalpaper

A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and paramedics.

7. Badge of Life. A study of police suicide 2008-2016. Facebook. 2016. Accessed September 6, 2022. 

https://www.facebook.com/law.enforcement.today/photos/a-study-of-police-suicide-2008-20152015-suicidesa-six-month-sampling-july-throug/10156954081320244/?_rdr

Differences in psychiatric symptoms and barriers to mental health care between volunteer and career firefighters.

9. Bentley MA, Crawford JM, Wilkins JR, et al. 

An assessment of depression, anxiety, and stress among nationally certified EMS professionals.

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. October 9, 2020. Accessed September 6, 2022. 

https://www.jems.com/spotlight/recognizing-and-supporting-ems-providers-with-mental-health-and-substance-use-disorders

11. First responders: behavioral health concerns, emergency response, and trauma. SAMHSA. May 2018. Accessed September 6, 2022. 

https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf

12. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. The National Occupational Mortality Surveillance (NOMS): Resource and related links. 2016. Accessed September 6, 2022. 

https://www.cdc.gov/niosh/topics/noms/link.html

13. Beidel DC, Frueh BC, Neer SM, Lejuez CW. 

The efficacy of trauma management therapy: a controlled pilot investigation of a three-week intensive outpatient program for combat-related PTSD.

14. Among Boston’s first responders. American Psychological Association. August 2013. Accessed September 6, 2022. 

https://www.apa.org/monitor/2013/07-08/first-responders

15. Dowling F, Moynihan G, Genet B, Lewis J. 

A peer-based assistance program for officers with the New York City Police Department: report of the effects of Sept. 11, 2001.

16. First Responder. Helpline. The University of Texas Health Science Center at Houston School of Biomedical Informatics. Accessed September 6, 2022. 

17. Vallejo A. Symptomatic changes in police officers with post-traumatic stress and group psychotherapy. 

18. Gersons BP, Carlier IV, Lamberts RD, van der Kolk BA. 

Randomized clinical trial of brief eclectic psychotherapy for police officers with posttraumatic stress disorder.

As Suicide Prevention Month continues, we take a look at the mental health of a group constantly caring for others: first responders.  

First Responders and Mental Health: When Heroes Need Rescuing

Resources for Suicide Prevention

September 4 to 10 is National Suicide Prevention Week, and September is National Suicide Prevention Month.

Suicide Prevention Week is September 4-10. This week, we at 

 want to highlight how best to support patients, friends, family, and anyone who might be having suicidal thoughts. We sat down with Manish Mishra, MBBS, the Chief Medical Officer of the Texas Healthcare and Diagnostic Center, to discuss.

PT: What does research say the role of alcohol/substances is in suicide?

Research on the link between alcohol and substances in 

 has been driven by the prevalent involvement of alcohol and substance abuse in suicide cases. There is a multitude of factors to be considered when examining the correlation between substance abuse and suicide as independent variables with an anecdotally strong interdependent relationship.

Historical data used to inform research suggests that across general populations, all types of 

 and substance use disorders are associated with increased risk for suicidal behaviors, including ideations, attempts, and fatalities. Substance abuse involving alcohol and illegal or prescription drugs is a much higher risk factor for suicidal mortality.

One of the reasons why alcohol and drug abuse is so strongly associated with suicide has to do with the psychological and psychosocial outcomes of untreated alcohol and drug dependence. Substance abuse and 

 often result in social isolation and marginalization, disruptions and conflicts in personal relationships, and aggravation of psychiatric symptoms such as depression and anxiety, all of which contribute to suicidal behaviors.

Another strong correlation is that alcohol and mind-altering substances are used as means of self-medication to cope with untreated mental health disorders, the symptoms of which are reciprocally exacerbated by substances. This causes a spiral effect of emotional decline and mental impairment that occurs with chronic alcohol and drug use and intoxication.

PT: People with alcohol use disorder are up 120 times more likely to commit suicide than those who are not dependent on alcohol.

 Psychoeducation on substance use and suicide for patients and their families seems to be more important than ever. In your experience, what are the best strategies for clinicians to broach this subject?

The abuse of alcohol or drugs is one of the most common risk factors for suicidal behavior. Although this is a difficult way of intervention and requires significant involvement and commitment from both patient and family members, psychoeducation has been proven to be effective in treating mental health disorders and managing the prognosis in the long run. Different strategies are used by clinicians to assess and manage symptoms and avoid remission. Some of the strategies commonly used are as follows:

1) Brief intervention to reduce suicidal behavior

These types of interventions are mostly used with postdischarge patients for follow-up. It can include postcards, letters, or even a phone call. It helps in reducing the patient’s sense of isolation contributing to decreasing future suicidal behaviors.

Brief motivational enhancement techniques to increase patients’ willingness to pursue treatment and overcome obstacles may also be an effective engagement approach. Motivational interviewing is focused on helping people work through their ambivalence about changing their behavior and explores patients’ concerns and beliefs about change.

Most important to motivational interviewing is to engage patients in a discussion that is noncoercive and nonthreatening, and to create an atmosphere that is empathic, nonjudgmental, and supportive of the patients’ concerns. Open-ended questions, affirmations, reflective listening, and summarizing are the cornerstones of this approach.

Early intervention after a suicide attempt is vital because the 3-month period after an initial attempt is when an individual is at the highest risk of additional suicidal behavior. Yet those who attempt suicide have been found to be very difficult to engage in treatment. These interventions can include outpatient or inpatient treatment depending upon the severity. Postcards and phone calls can both be used for the outpatient approach, whereas motivational interviewing has been more effective with inpatient treatment.

This strategy provides for participation in activities that exclude alcohol, tobacco, and other drug use. Constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by, alcohol, tobacco, and other drug use, which ultimately reduces suicidal tendencies.

PT: How can mental health clinicians improve the conversation surrounding this issue beyond the office?

Part of preventing suicide is raising awareness around the topic and bringing it into conversations. The topic of suicide is surrounded by secrecy, which is one of the barriers to getting treatment for people who need it. Mental health clinicians can play a part in dispelling the secrecy and stigma around suicide, and increase social empathy by discussing it as often and openly as other mental health issues are commonly verbalized.

As subject matter experts in their fields, mental health professionals have the capacity and agency to shed light on how prevalent suicidal behaviors actually are among general populations, and help to destigmatize suicide and associated mental health disorders. This stigma is a big reason why many people do not seek help for treatable mental health conditions and preventable tragedies.

PT: Global alcohol consumption has increased in recent decades, and is linked with more than 60 types of diseases and injuries.

 Should clinicians be talking to patients about healthy alcohol consumption levels, or even abstinence?

Many people who drink to excess would not categorize themselves as being alcoholics or having an 

. Many would also not consider broaching the subject to a clinician if they think it would be irrelevant, or they do not want to be labeled as someone with an alcohol problem. Clinicians are responsible for informing their patients of the dangers and risks associated with excessive alcohol consumption, including binge drinking and chronic intoxication, as a preventative protocol—not only as a response to an immediate health concern.

Even if someone does not fit all the criteria of an alcohol use disorder, they can still be at risk of developing alcohol dependence, putting their physical and mental health at risk due to alcohol abuse. Addressing alcoholism in a clinical setting and providing recommendations about setting limits or considering abstinence can help people make informed and conscientious decisions about their alcohol consumption.

PT: When devising a safety plan with patients, how do you discuss substance use?

Safety planning is a brief intervention to help individuals survive suicidal crises by having them develop a set of steps to reduce the likelihood of engaging in suicidal behavior. Safety planning is frequently included as an element in cognitive behavioral interventions for suicide prevention and can also be used as a brief standalone intervention, typically paired with a referral for mental health treatment.

The role of the substance abuse treatment program is to provide safety for its clients: recognizing suicidality when it appears, having policies and procedures for addressing suicidal thoughts and behaviors, and ensuring that treatment for the substance use disorder is not lost in the suicidal crisis. A Treatment Improvement Protocol (TIP) developed a protocol, with the acronym GATE for discussing suicidality in patients with substance abuse. It is comprised of the following steps:

• Take action to ensure appropriate care and safety for the client.

• Extend the action beyond the immediate situation to promote ongoing treatment and safety.

PT: Why is it important for clinicians to be talking about alcohol, substance use, and suicide with teenagers and young adults specifically?

Studies have observed that people who start abusing alcohol and drugs in early adolescence greatly increase their risk of developing mental health disorders and 

Suicide Prevention Week is September 4-10. Are you ready? 

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